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Schizophrenia Research 203 (2019) 55–61

Contents lists available at ScienceDirect

Schizophrenia Research

journal homepage: www.elsevier.com/locate/schres

In and out of schizophrenia: Activation and deactivation of the negative


and positive schemas
Aaron T. Beck, Robyn Himelstein, & Paul M. Grant ⁎
Perelman School of Medicine, University of Pennsylvania, USA.

a r t i c l e i n f o a b s t r a c t

Article history: Theorists, clinicians, and investigators have attempted to find a common source for the negative and positive
Received 17 August 2017 symptoms of schizophrenia. We propose that a unified theory, based on a common cognitive structure not
Received in revised form 27 October 2017 only has explanatory value, but can serve as a framework for a psychotherapeutic intervention. Specifically, we
Accepted 30 October 2017
propose that the cognitive triad – the negative view of the self, others, and the future – is the source of the content
Available online 21 November 2017
for the negative and positive symptoms. We report literature supporting the relationship between each facet of
Keywords:
the negative triad and each of the key symptoms: expressive negative symptoms, delusions, and verbal halluci-
Cognitive model nations. We conclude that the literature supports the validity of the cognitive model of negative and positive
Schizophrenia symptoms. The cognitive model furthers the understanding of the positive and negative symptoms of schizo-
Negative symptoms phrenia, and we describe how this provides a framework for a psychotherapeutic intervention.
Delusions © 2017 Elsevier B.V. All rights reserved.
Hallucinations
Recovery

1. Introduction we have introduced the concept of cognitive schemas, which are re-
sponsible for cognitive organization (Beck and Haigh, 2014). These
Both negative and positive symptoms of schizophrenia can be ana- structures have a variety of characteristics, such as width (the extent
lyzed within the traditional cognitive model, in which the cognitive of situations encompassed by them), permeability, density (their ro-
triad (schemas about self, world, and the future) shapes beliefs, ap- bustness), intensity (their charge), and content. The durability of
praisals of events, and consequent responses. Stressful life events, child- schemas is reflected in their clinical manifestations. The chronic, contin-
hood trauma, and genetic predispositions (alone or combined) can uous persistence of the schema is a reflection of the density and the
result in the development of negative beliefs (such as, “I am unlovable,” acute intensity reflects the degree of charge. According to the theory,
“People are dangerous,” or “Things will never get better”), emotions content of the schemas originates in the cognitive triad (negative beliefs
(e.g. sadness) and maladaptive behaviors (e.g. withdrawal) (Beck and about the self, external situation, and the future), which are then trans-
Bredemeier, 2016). For both negative and positive symptoms, the con- lated into schemas pertaining to specific situations (e.g., “If I try some-
tent is similar: the view of the self as weak, vulnerable, ineffective, thing, I will only fail” or “people will reject me if I try to socialize”).
and worthless; the view of others as controlling, dangerous, rejecting; We label schemas as dysfunctional when they interfere with the adjust-
and the view of the future as uncertain or forbidding. The cognitive ment or accommodation to life situations. The schema is delusional
triad can also be used to develop effective treatments for individuals when the content is extreme or fantastic, and not subject to correction.
with schizophrenia. The individual's views of the self, others, and future
effect the presentation of negative and positive symptoms. We have 3. Development of schizophrenia
found that interventions that target the meaning behind both positive
and negative symptoms often ameliorate them. The early stages of the precursors to schizophrenia follow a similar
pathway to the development of non-psychotic disorders. Some individ-
uals may have an inherited predisposition consisting of a negative cog-
2. Schemas
nitive bias in the interpretation of life events. These individuals are
likely to over-interpret negative events or make negative interpreta-
In order to understand the fluctuation in the intensity, duration, and
tions of neutral events. As the totality of negative interpretations in-
frequency of the symptoms of schizophrenia, as well as other disorders,
creases over time, the individual develops relatively stable, negatively-
⁎ Corresponding author at: Department of Psychiatry, Perelman School of Medicine,
biased beliefs about the self, personal world, and future. These dysfunc-
University of Pennsylvania, 3535 Market Street, Room 3049, Philadelphia, PA 19104, USA. tional negative beliefs give rise to specific predictions and rules, such as
E-mail address: pgrant@mail.med.upenn.edu (P.M. Grant). “if I try this, I'm only going to fail” or “don't stick your neck out.” The

http://dx.doi.org/10.1016/j.schres.2017.10.046
0920-9964/© 2017 Elsevier B.V. All rights reserved.
56 A.T. Beck et al. / Schizophrenia Research 203 (2019) 55–61

negative beliefs become embedded in schemas. Other individuals may rejected.” The goal is to avoid hurt, frustration, and disappointment
not be genetically predisposed to the same type of negative cognitive through withdrawal, avoidance, and distancing. The symptoms in Factor
bias, but are subjected to so much negativity in their environment that I are more or less conscious and are readily attributable by the individ-
they eventually develop the same type of dysfunctional negative beliefs. ual to the dysfunctional attitude, for example, “I know I'm going to fail,
In the development of schizophrenia, the dysfunctional attitudes may so I won't try so hard.”. It is possible for the individual to rise above these
lead to negative symptoms of schizophrenia; specifically, withdrawal, beliefs and make an effort if the attraction to the activity is strong
avoidance, and isolation. enough to mobilize positive expectations. For example, an individual
The development of positive symptoms may start with the dysfunc- may feel too fatigued to become active and join a group of people, but
tional attitudes. Due to some genetically determined anomalous brain if they play music, start dancing, and serve refreshments, he may expe-
circuitry, the dysfunctional beliefs become transformed into delusions rience sufficient motivation to join in—in this case, the positive expecta-
and hallucinations, which constitute an exaggeration or bizarre expres- tion of the experience overrides the negative attitude.
sion of the dysfunctional belief. The development of positive symptoms
would follow the stressor pathway, beginning from the impingement of 4.2. Factor II of negative symptoms: Expressive factor
life events on the vulnerable, dysfunctional beliefs, leading to an exag-
geration of the life event and triggering a psychophysiological system: Factor II of the negative symptoms (Blanchard and Cohen, 2006;
overstimulation of the HPA axis → excessive output of cortisol → exces- Kelley et al., 1999) is manifested in the repertoire of interpersonal re-
sive flow of dopamine into the limbic and other regions of the brain → sponses that include facial expression, gestures, and speech. In contrast
development of delusions and hallucinations. to Factor I, these expressive symptoms occur automatically and in the
absence of conscious volition. Also, in contrast to the symptoms of Fac-
4. Negative symptoms tor I, which are dependent on a reduction in access to motivation or ef-
fort, symptoms of Factor II constitute an inhibition of behavioral
The negative symptoms are concerned with the individuals' behav- responses. In this sense, it is akin to freezing in cases of public speaking
ior: whether the individual becomes inactive or active. Motivation anxiety (inhibition of speech) and panic disorder (generalized inhibi-
plays a key role in the development of negative symptoms. Table 1 out- tion of motor activity). Taken together, Factor I and Factor II combine
lines the theoretical formulation of the relationship of the dysfunctional to promote inactivity and seclusion.
attitudes, regarding the three components of the negative cognitive
triad and their relationship to the negative symptoms. 4.3. Empirical basis for cognitive model of negative symptoms

4.1. Factor I of negative symptoms: Amotivation factor 4.3.1. Beliefs about the self
Beliefs about the self have been found to influence negative symp-
The symptoms in the last column represent Factor I of the Scale for toms. For example, positive evaluations of the self correlate with
the Assessment of Negative Symptoms (Andreasen, 1984; Kelley et al., fewer negative symptoms among individuals with schizophrenia
1999): the amotivation factor. According to the cognitive model, nega- (Barrowclough et al., 2003). On the other hand, negative self-concepts
tive beliefs are transformed into negative symptoms. For example, the related to interpersonal abilities, dysfunctional acceptance beliefs, and
dysfunctional belief, “I am broken,” illustrates the individual's beliefs global perceptions of the self as worthless, useless, and a failure signifi-
about the self. If the individual feels broken, then facing a task, demand, cantly correlate with the severity of negative symptoms among individ-
or even opportunity activates a belief consistent with the negative self- uals with schizophrenia, explaining over a third of the variance in
concept: “If I try something, I will fail.” This expectation then under- negative symptoms over and above the impact of depression and
mines access to motivation to attempt or accomplish the task. The neurocognition (Lincoln et al., 2011). Further, a longitudinal first epi-
self-attributes of the negative self-image are focused on weakness, sode study determined that increases in positive beliefs about the self-
worthlessness, and helplessness. The development of negative symp- predicted decreases in negative symptoms, while increases in negative
toms differ from the development of positive symptoms and are repre- beliefs about the self significantly predicted increases in negative symp-
sented by dysfunctional beliefs, such as “if I try something, I'm only toms (Palmier-Claus et al., 2011). Additionally, lower self-efficacy has
going to fail” or “no point in trying to fit in a social group, I'll only be been found to correlate with more severe negative symptoms among

Table 1
Situation-specific dysfunctional attitudes related to the amotivation factor1 of negative symptoms.

1
Andreasen, N.C., 1984. Scale for the Assessment of Negative Symptoms (SANS). University of Iowa, Iowa City, IA.
A.T. Beck et al. / Schizophrenia Research 203 (2019) 55–61 57

individuals with non-affective psychosis (Avery et al., 2009). Negative Most generally, research appears to support the cognitive model of
symptoms, further, appear to mediate the link between self-efficacy negative symptoms in terms of beliefs about the future and behavior.
and real-world functioning (Pratt et al., 2005; Vaskinn et al., 2015). Findings suggest that in individuals with schizophrenia, negative symp-
Two studies have found that amotivation (Factor I) mediates the rela- toms mediate the relationship between defeatist performance beliefs
tionship between self-efficacy and functioning in individuals experienc- and functioning (Horan et al., 2010) and, further, that specifically
ing a first episode of psychosis (Chang et al., 2017; Ventura et al., 2014). amotivation mediates the relationship between defeatist performance
beliefs and functional outcome (Pillny and Lincoln, 2016).
4.3.2. Defeatist beliefs
Beliefs about the future have also been found to influence negative
5. Positive symptoms
symptoms and functioning. Beliefs about future success (e.g. “I will
fail”) correlate with more severe negative symptoms (Cox et al.,
5.1. Delusions
2016). Similarly, defeatist beliefs (overly generalized negative conclu-
sions regarding task performance (Beck et al., 2009)) influence negative
The formation of delusions and hallucinations is the function of a
symptoms and functioning among individuals with schizophrenia or
cognitive system we labeled the transformational/imaginal system.
schizoaffective disorders (Green et al., 2012). These beliefs significantly
This anomalous system is self-contained and isolated from other cogni-
correlate with negative symptoms in individuals with schizophrenia
tive functions, such as reevaluation, logic, rationality, and reality testing,
(Granholm et al., 2016; Grant and Beck, 2009), ultra-high risk adoles-
which are earmarks of the basic cognitive system. The delusional prod-
cents and young adults (Perivoliotis et al., 2009), and individuals with
ucts that arise from negative attributes of the cognitive triad generally
elevated schizotypy (Luther et al., 2016). Those with either more severe
represent a symbolic, exaggerated transformation of the individual's
avolition/apathy or more severe diminished expression exhibited more
fears (paranoid delusions) or an extreme fantastic compensation (gran-
severe dysfunctional attitudes and poorer functioning (e.g. work and so-
diose symptoms). In the course of compensation, the grandiose delu-
cial functioning) (Strauss et al., 2013). Other findings similarly show de-
sions embody basic universal needs and urges, such as wanting to be
featist beliefs significantly correlate with functional outcomes (Grant
valued and accepted. The negative symptoms, in contrast, represent
and Beck, 2009) and predict future community participation (Thomas
the expectancy of failure in social or non-social situations. The various
et al., 2017). In addition, individuals who meet criteria for the deficit
types of delusions can be traced back to the features of the cognitive
syndrome (characterized by more severe and persistent negative symp-
triad. Paranoid or persecutory delusions, such as the fear of being killed
toms) endorse defeatist beliefs to a greater extent than those with less
or belief in being poisoned, can be seen as an extreme portrayal of other
severe negative symptoms (Beck et al., 2013). Lastly, a recent meta-
people being dangerous or rejecting. This could also take the form of so-
analysis of 10 studies concluded that defeatist beliefs were significantly
cial anxiety, in which the negative judgments of others trigger a need to
associated with negative symptoms and functional outcomes in schizo-
avoid social encounters. The grandiose delusions, on the other hand,
phrenia (Campellone et al., 2016).
have a more convoluted development. The content appears to emanate
Treatment studies further demonstrate the role of defeatist beliefs in
from a more profound view of the self as weak, controlled, and
negative symptoms. For instance, defeatist beliefs mediated improve-
devalued. In the case of both types of delusions, we have found that a
ment in negative symptoms in response to cognitive behavioral social
therapeutic treatment plan can diminish the impact of these delusions.
skills training (Granholm et al., 2014; Granholm et al., 2013). Our
For example, individuals with paranoid delusions may decrease their
group conducted a randomized clinical trial evaluating the efficacy of
guard and become less fearful when they have a series of positive social
cognitive therapy for individuals with schizophrenia having elevated
experiences and, particularly, become active in a social network. We
negative symptoms. Individuals receiving cognitive therapy had signif-
have also observed that individuals with grandiose delusions benefit
icantly better global functioning, ameliorated negative symptoms, and
from corrective experiences that have an impact on their sense of weak-
reduced positive symptoms at the end of treatment, compared to stan-
ness and undesirability. For example, when these individuals have the
dard treatment in the community (Grant et al., 2012).
opportunity to help other people, they are empowered and conse-
quently, their delusional thinking and negative symptoms are reduced.
4.3.3. Anticipatory beliefs about pleasure
Research findings support anticipatory beliefs regarding pleasure
(e.g., “I won't enjoy the activity”) playing a role in negative symptoms. 5.2. Voices
Findings consistently suggest that decreased expectations of pleasure
correlate with more severe negative symptoms among individuals Individuals normally experience a variety of thoughts that appear in-
with schizophrenia (Chan et al., 2010; Da Silva et al., 2017; Engel et voluntarily in the stream of consciousness and are called automatic
al., 2016; Gard et al., 2007; Loas et al., 2009; Mote et al., 2014) and thoughts (Beck, 1976). These automatic thoughts can be self-evaluative,
healthy individuals (Engel et al., 2013). Reduced anticipatory pleasure critical or positive; injunctions or commands; thoughts about other
correlates specifically with more severe anhedonia (Davidson et al., people and events. Auditory hallucinations mirror the content of these
2005; Gard et al., 2007; Loas et al., 2009) and amotivation (Da Silva et thoughts and are experienced as vocalized, from a source that can be ei-
al., 2017; Engel et al., 2013). Similarly, impairments in the representa- ther known or unknown to the individual. The designated (projected)
tion of rewards correlate with negative symptoms among individuals vocalizer of the thought may be other known individuals, such as the
with schizophrenia (Gold et al., 2012). neighbors, or unknown individuals. It could be a spirit, a god, dead
loved one. The command hallucinations are generally ascribed to
4.3.4. Asocial beliefs some all-powerful individual, such as God, or some unidentified entity.1
Beliefs about future interpersonal interactions (e.g., “If I socialize, I Like delusions, voices reflect the negative view of the self, others, and
will be rejected”) can influence negative symptoms. Asocial beliefs can be threatening about the future. An individual reported, for exam-
(e.g., “Making new friends isn't worth the effort it takes”) correlate ple, that the voice of God commanded her to vacuum the living room
with asociality in schizophrenia (Grant and Beck, 2010), and individuals every day or she would get killed. The fear of being punished is in this
who meet criteria for the deficit syndrome endorse asocial beliefs more way expressed as an absolute command.
than individuals with less negative symptoms (Beck et al., 2013). Ele- As in delusions, the voices are embedded in the transformational/
vated asocial beliefs have been found to be an independent path from imaginal system and thus, tend to be absolute and irrefutable. However,
defeatist beliefs that also predict decreased community participation
in the future (Thomas et al., 2017). 1
Command hallucinations are verbal imperatives that implore action.
58 A.T. Beck et al. / Schizophrenia Research 203 (2019) 55–61

as noted above, they do reflect individuals' non-delusional automatic (along with negative beliefs about the self) mediated the link between
thoughts, which are attached to real experiences. By working with and trauma and paranoia among students (Gracie et al., 2007), and negative
reframing non-delusional automatic thoughts, it is possible to disem- beliefs about others significantly and fully mediated the relationship be-
power the voices. Similarly, improvement in the view of the self and tween loneliness and paranoia among individuals with schizophrenia
others may, over time, diminish the severity and distress associated (Lamster et al., 2017). There was evidence supporting a directional
with voices. pathway from negative cognition (which included negative views
about others) and depressed mood to paranoid symptoms but no evi-
5.3. Empirical basis for cognitive model of delusions dence in support of directional pathways leading from paranoia to neg-
ative cognition or from paranoia to depressed mood (Fowler et al.,
5.3.1. Beliefs about the self 2012).
Recent research has found that negative-self schemas to be a predic-
tor of negative affect and positive symptoms, which suggests that nega- 5.3.3. Beliefs About the Future
tive beliefs about the self occur first (Jaya et al., 2017). Beliefs about the Depressed individuals, depressed individuals with persecutory delu-
self have been shown to impact delusion content, level of comfort with sions, and non-depressed individuals with persecutory delusions rated
delusions (Bowins and Shugar, 1998), and severity of delusions future negative events as happening more frequently than did unaf-
(Barrowclough et al., 2003). Also, lower self-esteem, more negative fected controls (Kaney et al., 1997). In a virtual reality study on individ-
evaluations of the self, and less positive evaluations of the self correlate uals with an at-risk mental state, interpersonal sensitivity (feeling
with the severity of persecutory delusions (Garety et al., 2013), includ- vulnerable in the presence of others due to the expectation of criticism
ing greater distress and preoccupation regarding the delusions (Collett or rejection) was one of the factors predicting persecutory ideation in
et al., 2016; Kesting and Lincoln, 2013; Smith et al., 2006; Sundag et the virtual reality environment (Valmaggia et al., 2007). Additionally,
al., 2014), higher perceived deservedness of the persecution (Kesting non-psychotic individuals with depression and individuals with schizo-
and Lincoln, 2013), and greater suicidal ideation (Collett et al., 2016). phrenia, schizoaffective disorder, or delusional disorder who experi-
By contrast, beliefs that the self is powerful correlate with decreased dis- enced paranoid delusions were found to believe that pleasant things
tress (Paget and Ellett, 2014). Negative evaluative beliefs about the self would not happen to them. This pessimistic thinking was not present
are still significantly correlated with persecutory delusions when de- in individuals whose paranoid delusions were in remission (Corcoran
pression and self-esteem are statistically controlled (Smith et al., 2006). et al., 2006). In a sample of individuals with schizophrenia, depression,
For individuals with grandiose delusions, positive beliefs about the or healthy controls, negative self-esteem and expectations of negative
self and less negative beliefs about the self correlate with delusion se- events strongly and independently correlated with paranoia in all
verity (Garety et al., 2013; Smith et al., 2006). Moreover, one study groups. Moreover, predictions of future negative events and negative
established that positive views of the self strongly and uniquely pre- self-esteem accounted for more than half of the sample variance in
dicted grandiosity in a non-clinical sample (Fowler et al., 2006). Para- paranoia scores (Bentall et al., 2008). Recent findings highlight how
noid thinking significantly correlates with less positive views of the paranoia correlates with anticipation of future threatening events
self and more negative views of the self among nonclinical (Fowler et among individuals with delusions (Freeman et al., 2013) and victimiza-
al., 2006; Gracie et al., 2007) and clinical samples (Freeman et al., tion among nonclinical individuals (Jack and Egan, 2016).
2013; Tiernan et al., 2014; Valiente et al., 2014) after controlling for de-
pression (Valiente et al., 2014). One study found support for a direc- 5.4. Empirical basis for cognitive model of voices
tional pathway from negative cognition (low self-esteem, self-critical
thinking, and extreme negative beliefs about the self and others) and 5.4.1. Beliefs About Self
depressed mood to paranoid symptoms, but no support of directional Among individuals with schizophrenia, negative views of the self
pathways leading from paranoia to negative cognition (or from para- and low self-esteem correlate with voices (Barrowclough et al., 2003;
noia to depressed mood) (Fowler et al., 2012). In an experimental Close and Garety, 1998) and negative views correspond to hearing
study, nonclinical individuals from the general population were ex- voices that are more distressing (Paulik, 2012; Smith et al., 2006), neg-
posed to a computer-generated 3D environment that elicited paranoid ative (Close and Garety, 1998; Smith et al., 2006), and severe (Smith et
thoughts in a proportion of them. In line with the cognitive model, emo- al., 2006). Voices also correlate with more negative views of the self and
tional disturbance, negative views of the self, and a greater tendency to less positive views of the self (Gracie et al., 2007; Noone et al., 2015)
experience perceptual anomalies predicted paranoid ideas (Freeman et among nonclinical samples. Beliefs about voices can also reflect beliefs
al., 2005). Negative beliefs about the self and others have also been about the self. For example, Thomas et al. (2015) determined that neg-
found to account for the association between trauma and paranoia ative beliefs about the self significantly predicted negative beliefs about
(Fisher et al., 2012; Gracie et al., 2007). voices (malevolence, omnipotence, metaphysical beliefs, and loss of
control) in a sample of individuals with schizophrenia or schizoaffective
5.3.2. Beliefs about others disorder.
Smith et al. (2006) found that negative beliefs about others were one
factor that corresponded to more severe persecutory delusions and 5.4.2. Beliefs about others
more preoccupation and distress about the delusions in individuals Individuals with schizophrenia may believe their voices are malevo-
with schizophrenia. Beliefs of inferiority to others (Collett et al., 2016) lent (Baumeister et al., 2017; Chadwick et al., 1994; Thomas et al.,
and beliefs that others are more omnipotent and malevolent than the 2015), benevolent (Chadwick et al., 1994; Thomas et al., 2015), omnip-
self (Paget and Ellett, 2014) correlate with persecutory delusions. In ad- otent/powerful (Baumeister et al., 2017; Thomas et al., 2015), omni-
dition, persecutory delusions may involve specific beliefs about the per- scient (Paulik, 2012), external and real (Garrett and Silva, 2003), are
secutor. For instance, Paget and Ellett (2014) found that beliefs about of higher social rank and power than the individual (Birchwood et al.,
the persecutors' omnipotence predicted persecutory delusion convic- 2004; Paulik, 2012), or indicate that they are losing control or are
tion. Further, more negative views of others (e.g., as hostile, harsh, going mad (Morrison, 1998). Nonclinical voice hearers may believe
nasty, untrustworthy) correlate with paranoia in clinical (Valiente et the voices indicate that they have done something bad or are a bad per-
al., 2014) and nonclinical samples (Fowler et al., 2006; Gracie et al., son (Morrison et al., 2002).
2007) after accounting for depression, and this relationship may be A systematic literature review by Paulik (2012), including 13 studies
present in non-diagnosed children with emotional and behavioral prob- published from 2000 to 2010, highlighted the importance of interper-
lems (Noone et al., 2015). Moreover, negative beliefs about others sonal relationships in the experience of voices. They found that voice
A.T. Beck et al. / Schizophrenia Research 203 (2019) 55–61 59

hearers, who perceived themselves to be of low social rank or inferior dysfunctional attitudes associated with the negative cognitive triad,
relative to others, reported they also felt inferior in relation to their which are understandable in terms of normal cognitive processing.
voice and behave accordingly. The positive symptoms, however, diverge from the ordinary cognitive
Because individuals see voices as other than themselves, the beliefs processing and its content is transformed into unrealistic or irrational
about voices are related to beliefs about others. For example, among ideation.
clinical samples, distress correlates with believing that the voices are For the most part, the literature on the cognitive approaches to
malevolent, omnipotent, uncontrollable, dangerous (Baumeister et al., schizophrenia (as well as other disorders) has focused on the negative
2017), or of higher social rank and power than the individual beliefs, attitudes, etc. Nonetheless, there are sets of positive adaptive be-
(Birchwood et al., 2004). Among nonclinical individuals, distress corre- liefs, which are the opposite of the negative dysfunctional beliefs. Thus,
lates with believing that the voices indicate that the individual has done parallel to negative dysfunctional beliefs revolving around inadequacy,
something bad, is a bad person, or is possessed (Morrison et al., 2002). unworthiness, and weakness, are sets of positive adaptive beliefs in-
Among individuals with schizophrenia, fear and anger correlate with volving adequacy, worthwhileness, and strength. Both positive and neg-
believing the voices are malevolent (Birchwood and Chadwick, 1997), ative beliefs form the content of schemas. To the extent that positive
and depression correlates with believing the voices are malevolent schemas are activated, there is a corresponding deactivation of negative
(Andrew et al., 2008). Furthermore, a review concluded that cognitive schemas.
appraisals of voices (e.g., the intent of the voice, power/omnipotence, It is important to utilize the cognitive model of delusions and hallu-
omniscience, and control) are more closely linked to the affective and cinations in formulating a case and developing a treatment plan. When
behavioral responses to the voices than the voice severity or content the specific interactions leading to an individual's sense of inferiority are
(Paulik, 2012). not apparent, the meanings behind the delusions and hallucinations can
be used to understand the individual's reactions. For example, a woman
6. Modes who believed that her family was poisoning her also had a steady
stream of voices criticizing her, based on her interactions with the fam-
The concept of mode is useful for understanding times when indi- ily. The formulation focused on her sense of inferiority and vulnerability
viduals with schizophrenia are doing better and worse. The mode is in relationship to members of her family. She started to bake pastry for
an integrated, situation specific system involving cognition (beliefs other individuals on the unit and gradually moved to instructing them.
and attitudes), affect, motivation, and behavior. It is useful to distinguish She then felt confident enough to cook a meal for her family. As she
an adaptive mode from a “patient” mode. The adaptive mode is active moved from inactivity, to cooking and instructing others, her ideas
when individuals are playing a game, listening to an orchestra, or teach- about being poisoned and the critical voices gradually diminished. Fol-
ing a class. In individuals with schizophrenia who seem to face a more lowing successful preparation of meals for her family, she no longer re-
challenging course of illness, however, the “patient” mode is dominant ported her delusions and voices. She was now in the adaptive mode.
and spreads across all situations. In a hospital unit, the prevalent cogni- In order to develop effective treatment interventions, a thorough un-
tion consists of a medley of attitudes such as; I am inadequate, broken, derstanding of the mechanisms behind the development of schizophrenia
worthless, undesirable, useless, alone, etc. If faced with a task, the ex- is needed. Thus, we have used our understanding of the cognitive model
pectations are of social failure. Therefore, the motivation is to avoid, re- and cognitive triad to guide our treatment interventions for this popula-
treat, escape, and the resulting behavior is to withdraw. Each tion. In treating the severely mentally ill, we have noticed that as the indi-
component is associated with unpleasant affect; particularly the expec- viduals become more symptomatic, there is an increased activation of the
tations of failure and after an attempt at a task is made, the interpreta- negative beliefs. On the contrary, when the individuals start to improve,
tion is failure. Performance is evaluated and interpreted in terms of there is an increasing activation of the positive beliefs. With improve-
the overlying attitude, which is “I am a failure.” The goal of therapy is ment, the negative beliefs may gradually become totally deactivated.
to engage the individual and structure the experience in such a way Our observation of the activation of positive beliefs has led to the for-
that the individual will interpret it as a success rather than a failure; mulation of Recovery-Oriented Cognitive Therapy which focuses on the
experiencing positive rather than unpleasant affect. At times individuals positive aspirations, strengths, and values of the individual. In theoreti-
can shift from one mode to another. Individuals who perceive that they cal terms, the adaptive mode gradually replaces the “patient” mode.
are unfairly treated can become angry and strike out against the of- Problems occur after the individual is rooted in the community and
fender but then relapse into the “patient” mode of inactivity. subject to the kinds of stresses and strains that activated their disorder
We have noticed on numerous occasions that even when individ- in the first place. It is important, consequently, to train the individuals
uals' delusions are very active they can at times show personalities in the use of cognitive skills to prevent unpleasant situations from be-
that are in stark contrast to the personalities when they are in a “pa- coming stressors, for example looking at the evidence and drawing a
tient” mode (negative and/or positive symptoms). During special conclusion, considering alternative explanations, and examining the
events on the unit, for example, they can sing and dance, play games, logic behind a conclusion. The individual's reasoning powers are
or act in plays so effectively that they are not distinguishable from the strengthened, making him/her less vulnerable to negative situations.
staff. Of course, the therapeutic program is geared to activating these as- The research to date has concentrated on the negative content of the
pects of the personality, when the individuals are engaged in something individual's beliefs, but little attention has been paid to positive adap-
meaningful or that has purpose. The “patient” mode is no longer appar- tive beliefs. In clinical trials in particular, it is important to assess the
ent. In due course, the laughing and making jokes, as well as the rest of roles of positive, as well as negative beliefs. As the individual improves,
the adaptive mode is activated for longer periods, until the individual the progress can be attributed to the increased activation of positive
can remain in this mode. To promote generalization, one very effective adaptive beliefs, more so than the deactivation of negative dysfunc-
strategy is drawing conclusions (cognitive restructuring) to strengthen tional beliefs. Of course, this has to be demonstrated in clinical or exper-
positive beliefs after positive corrective experiences. imental studies nationwide.

7. Discussion
References

Both negative and positive symptoms can be analyzed within the Andreasen, N.C., 1984. Scale for the Assessment of Negative Symptoms (SANS). University
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